Provider Demographics
NPI:1922569938
Name:YAMAGUCHI, GREGORY (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:YAMAGUCHI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4609
Mailing Address - Country:US
Mailing Address - Phone:310-749-1217
Mailing Address - Fax:
Practice Address - Street 1:250 N ROBERTSON BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1767
Practice Address - Country:US
Practice Address - Phone:310-385-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002373152W00000X
CAOPT34640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist